Tis more blessed to give than to receive? Groundbreaking new outcomes research altruistic emotions and helping behavior

Does a kindly, charitable interest in others (benevolence, good will, love, kindliness) have health benefits for the agent, particularly when coupled with helping behaviors? Increasingly, such emotional states and the related behaviors of serving others freely without reward are being studied by mainstream scientists in relation to health promotion and disease prevention (Young & Glasgow, 1998; Oman, Thoresen, & McMahon, 1999). If helping affect and/or behavior can be linked with health and longevity, the implications for how we think about human nature and prosperity are enormous (Levin, 2000).

It is difficult to imagine a more powerful scientific basis for encouraging kindliness in society than this, although such evidence would raise the question of whether the prudential knowledge of health benefits would undermine the essential disinterestedness of motive that is associated with true kindness. There is a difference between the phrase "In the giving of self lies the health of the self," and "In the giving of self lies the unsought for health of the self." Perhaps concern with purity of motive underlies some of the scientific inattention to the impact of charity on its agents. But purity aside, science must proceed.

Stephanie Brown (2003) reports in Psychological Science on a 5-year study involving 423 older couples. Each couple was asked what type of practical support they provided for friends or relatives, if they could count on help from others when needed, and what type of emotional support they give each other. A total of 134 people died over the five years. After adjusting for a variety of factors  including age, gender, and physical and emotional health  the researchers found an association between reduced risk of dying and giving help, but no association between receiving help and reduced death risk. Brown, a researcher at the University of Michigan's Institute for Social Research, concluded that those who provided no instrumental or emotional support to others were more than twice as likely to die in the five years as people who helped spouses, friends, relatives, and neighbors. Despite concerns that the longevity effects might be due to a healthier individual's greater ability to provide help, the results remained the same even after the researchers controlled for functional health, health satisfaction, health behaviors, age, income, education level, and other possible confounders. Future research is needed to replicate Brown's study, which was covered in the New York Times and many other leading media venues in the U.S., Europe, and Asia.

Some of the best work on this topic is that of Doug Oman of the Buck Center for Research in Aging and the University of California at Berkeley. Oman, et al. (Oman, Thoressen & McMahon, 1999) focused on 2025 community-dwelling residents of Marin County, California, who were first examined in 1990-1991. All respondents were 55 or older at this baseline examination; 95 percent were non-Hispanic white, 58 percent were female, and a majority had annual incomes above $15,000. Residents were classified as practicing "high volunteerism" if they were involved in two or more helping organizations, and as practicing "moderate volunteerism" if they were involved in one. The number of hours invested in helping behavior was also measured, although this was not as predictive as the number of organizations. Physical health status was assessed on the basis of reported medical diagnoses, as well as such factors as "tiring easily" and self-perceived overall health.

31% (n=630) of these elderly participants participated in some kind of volunteer activity, and about half volunteered for more than one organization. Those who volunteered for two or more organizations experienced a 63% lower likelihood of dying during the study period than did non-volunteers. Even after controlling for age, gender, number of chronic conditions, physical mobility, exercise, self-rated general health, health habits (smoking), social support (marital status, religious attendance), and psychological status (depressive symptoms), this effect was only reduced to 44 percent -- still highly significant. Observational physical performance measures and self-reported functioning measures were included. Sociodemographic data were collected, as well as information on social functioning and support. Frequency of attendance at religious services was included in the many social functioning questions. Psychological measures were implemented as well.

Mortality was determined by screening local newspapers, attempted contact for reinterview at the time of a second interview, and submission of names to the National Death Index. Mortality was examined from 1990 through November 13, 1995, the closing date of the second examination. During this follow-up period of 3.2 to 5.6. years, 203 (23.8 percent) of men and 247 (21.1 percent) of women died. Remarkably, "The mortality rate of 30.1 among non-volunteers declined by 26 percent to 24.2 (p = .04) among moderate volunteers, and by an additional 50 percent to 12.8 (p = .008) among high volunteers (two or more organizations)" (p. 307). Multivariate adjusted associations indicated that moderate volunteerism was not statistically significant after controlling for health status. High volunteerism remained significantly associated with lower mortality rates. Specifically, "the 44 percent reduction in mortality associated with high volunteerism in this study was larger than the reductions associated with physical mobility (39 percent), exercising four times weekly (30 percent), and weekly attendance at religious services (29 percent), and was only slightly smaller than the reduction associated with not smoking (49 percent)" (p. 310). The precise relationship between religious and volunteer involvement is unspecified.

These are interesting results. Oman, et al. highlight Reissman's (1965) "helper-therapy principle" i.e., that the agents of helping behavior benefit in many ways. They point as well to Midlarsky's (1991) five reasons for benefit to the agents of such behavior  enhanced social integration; distraction from the agent's own problems; enhanced meaningfulness; increased perception of self-efficacy and competence; and improved mood or more physically active lifestyle. Midlarsky and Kahana (1994) associated adult helping behavior with improved morale, self-esteem, positive affect, and well-being - all with psychoneuroimmunological implications. Oman, et al. conclude that "if the present results are sustained, then voluntariness has the potential to add not only quality but also length to the lives of older individuals worldwide" (p. 314).

On a cross-cultural level, Neal Krause and colleagues (1999) at the University of Michigan studied a sample of 2153 older adults in Japan, examining the relationships between religion, providing help to others, and health. They found that those who provided more assistance to others were significantly more likely to indicate that their physical health was better. The authors concluded that the relationship between religion and better health could be at least partly explained by the increased likelihood of religious persons helping others.

Researchers such as Oman, Brown, and Krause are giving empirical grounding to what Erik Erikson and Pitirim Sorokin argued for anecdotally  i.e., generous behavior and kindness result in increased health and longevity. The Eriksonian assertion that "generativity" enhances longevity has recently been substantiated in a prospective longitudinal study by Harvard's George E. Vaillant, a prominent research psychiatrist who draws on over five decades of data from the Harvard Study of Adult Development. In his volume, entitled Aging Well (2002), Valliant reports that generative helping behavior focused on others is among the strongest predictors of health and longevity.

The benefits of altruism are not limited to older adults, although the differences in health outcomes between helpers and non-helpers is more difficult to detect in younger age groups, where health is not affected by susceptibilities associated with aging. Ironson and colleagues (2002) at the University of Miami compared the characteristics of long-term survivors with AIDS (n=79) and an HIV-positive group that had been diagnosed for only a relatively short time (n=200). These investigators found that survivors were significantly more likely to be religious. The effect of religiousness on survival, however, was mediated by "helping others with HIV." Thus, helping others (altruism) completely explained the relationship between religiousness and survival in this study. (In an earlier study, Omoto and Snyder (1995) examined the motivations AIDS volunteerism generally, but not the health and longevity of volunteers.)

The childhood development of kindness and helping behavior takes on a new level of significance when it is linked to life-long gains in health and longevity. A rather significant initial literature indicates that adolescents who involve themselves, whether entirely voluntarily or not, in helping behavior and service tend to be shielded from depression, anti-social behavior, and suicide. In addition, they tend to do better academically. (This latter detail should catch the attention of a great many hopeful parents.) So start helping others while young.

The above studies, all conducted by well-regarded researchers and published in rigorous peer-reviewed journals, suggests that this new area in positive psychology and health is beginning to stir. Prolongevity, of course, is on the minds of the baby boomers. It is odd to realize that while biogerontologists interested in prolongevity work with anti-oxidation theories, telomerase inhibition, "immortalized" stem cells, and other biochemical approaches, one route to prolongevity may well lie in untapping our capacities to love others altruistically (Post and Binstock, 2003). Yet there have been relatively few studies on this important topic. What is more worthy of systematic exploration than the health impact of compassionate love and service on both givers and receivers?

Two caveats must be added. First, the quickest way to undermine and destroy the helping impulse and its possible benefits to the agent is to exploit it to the point of exhaustion and deterioration. Despite the realization that the giving of self may generally lead to a healthier and longer life, every individual has psychological and physical limits, although some remarkable people seem to manifest almost unlimited altruism. (Even such "altruistic saints" may in some instances die young at the hands of their adversaries.) Granted such limits, there is nevertheless benefit in the transformation from solipsistic "I-It" relations, in which others are related to only insofar as they contribute to "my" agendas, to "I-Thou" relations, in which I relate to others on the basis of equality, dignity, and need. Second, the idea that there may be benefits in helping behavior and affect with regard to prolongevity and health need not reduce generosity to mere prudence. Genuinely motivated kindness can give rise to an enhanced sense of community, as well longevity and self-esteem, although these outcomes need not be directly sought and they are never certain. Thus, the paradox: in the giving of self lies the unsought-for discovery of self. There is no need to dismiss the motivational authenticity of love for others on the basis of knowledge that such love may be good for the agent as well as the recipient. Imagine a psychiatrist or cardiologist recommending that a patient cultivate kindness and helping activities, however difficult it is for many patients to change their behaviors even in the light of the clearest epidemiological data.

Is there a physiologic model for any link between health and a generous heart? One can imagine all sorts of possible physiological explanations for any association between kindliness and health. Kindness, benevolence, and helping activities might: (1) crowd out emotions such as anger, fear, and anxiety, which give rise to stress, and thereby switch off the "fight-flight response"; (2) allow for better coping with life's challenges; and (3) elevate self-esteem. These models are interconnected, although the first seems most consistent with a small phrase from the religious tradition I know best, "There is no fear in love, but perfect love casts out fear…" (I John 4:18) The "fight-flight" response, with its well documented physiological cascade, is adaptive in the face of perceived imperilment. However, if the threat continues for an extended period, the immune and cardiovascular systems are adversely impacted, weakening the body's defense and making it more susceptible to abnormal internal cellular processes involved in malignant degeneration (Sternberg, 2001).

Yet there may be something happening in the body that goes beyond switching off the fight-flight response. Immediate and unspecified physiological changes may occur as a result of volunteering and helping others, leading to the so-called "helper's high" (Luks, 1988). Two-thirds of helpers report a distinct physical sensation associated with helping; about half report that they experienced a "high" feeling, while 43 percent felt stronger and more energetic, 28 percent felt warm, 22 percent felt calmer and less depressed, 21 percent experienced greater self-worth, and 13 percent experienced fewer aches and pains. Despite these reports, the physiological changes that occur in the body during the process of helping others have not yet been scientifically studied.

Norman B. Anderson (2003) of the American Psychological Association highlights six dimensions of health:

biology (biological well-being)

thoughts and actions (psychological and behavioral well-being)

environment and relationships (environmental and social well-being)

personal achievement and equality (economic well-being)

faith and meaning (existential, religious, spiritual well-being)

emotions (emotional well-being)

According to the Anderson model, positive emotions (kindness, other-regarding love, compassion, etc.) enhance health simply by virtue of pushing aside negative ones. The generous affect that gives rise to love of humanity is usually associated with a certain delight in the affirmation of others; it even seems to cast out the fear and anxiety that emerge from preoccupation with self. Anderson draws on a wealth of studies to conclude that "the big three" negative emotions are "sadness/depression, fear/anxiety, and anger/hostility" (2003, p. 243). It is difficult to be angry, resentful, or fearful when one is showing unselfish love toward another person.

Many emotions can evoke the fight-fight response: stress (fear, anxiety, worry, or sense of time pressure); aggressive emotions, such as anger, resentment, or bitterness (from unforgiveness); depressive emotions, such as sadness, boredom, loss of purpose, meaning or hope. The consequences of these negative emotional responses are increased susceptibility to disease and worse health outcomes. Little research has examined the effects of altruistic love (compassion, kindness, desire to help others) on immune or cardiovascular function. There is evidence, however, that this positive emotion may have similar effects to those of social support and stress reduction on the flight-flight response.

Educational relevance: Schools of medicine and nursing teach that empathy and attentive listening, which affirm the feelings and perspectives of patients and are the beginning points for compassionate love, are important aspects of therapeutic efficacy. It might enhance students' attentiveness to the value of compassionate and altruistic love in professional life and service to patients if we could introduce high-level empirical studies indicating that these emotional and relational states of being are good for the agent as well as the patient. Often, empathy, compassion, and commitment to the patient's good are squeezed out of the healthcare system by monetary pressures or the sense that healing only results from biological and technological expertise. Perhaps the loss of these more altruistic emotions and behaviors contributes to caregiver burnout, ill health, and shortened lives. The problem of low staff morale and burnout is growing in both medicine and nursing, making it difficult to hire and retain staff and affecting the quality of patient care (Aiken, et al., 2002; Schroeder SA, 1992; Stechmiller J, 2002).

Some Key Questions: There is little scientific research to date on health outcomes for the agent of kindness and helping behavior. The Institute for Research on Unlimited Love identifies these questions as significant:

Is altruistic love a protective factor against morbidity and mortality in the agent and/or the recipient?

Does altruistic love promote health, psychological well-being, and high-level wellness in the agent and/or the recipient?

Does altruistic love exhibit or enhance therapeutic efficacy?

Under what conditions can altruistic actions become "burdens" rather than sources of meaning and fulfillment, and how does worldview come into play?

Is compassionate love a salutary component of the patient-provider relationship?

What are the physiological mediators of the love-health and love-healing relationships?

What are the psychosocial mediators of the love-health and love-healing relationships?

Are there psychophysiological correlates of giving or receiving love?

Can new assessment instruments for compassionate love be developed and validated?

What are the most promising theoretical and conceptual models of altruistic love?

Do those who score high on altruism or empathy scales do better at choosing "attachment solutions" during separation stress or challenge?

Is the generativity that develops in later adult life on a continuum of human development with otherregarding love earlier in life?

What are the neuropsychiatric elements of the human development of love?

What do we know about how we can teach altruistic behavior and empathy?

Is there a genetics of compassionate love?

Do conditions of "brokenness" free us from inauthentic or routinized existence and provoke a response of other-regarding love?

In summary, how does the giving and receiving of compassionate love, coupled with "works of love," impact both agent and recipient in terms of health. If we could answer these questions with high-quality research, the impact of such knowledge would have enormous effects on healthcare and on the way that everyday people live their lives. This effort is crucial to the human future, human dignity, and a common humanity.

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